Skip to main content Accessibility help
×
Home
Hostname: page-component-684899dbb8-vtfg7 Total loading time: 0.223 Render date: 2022-05-24T16:45:20.011Z Has data issue: true Feature Flags: { "shouldUseShareProductTool": true, "shouldUseHypothesis": true, "isUnsiloEnabled": true, "useRatesEcommerce": false, "useNewApi": true }

Pediatric Hyperacute Arterial Ischemic Stroke Pathways at Canadian Tertiary Care Hospitals

Published online by Cambridge University Press:  11 February 2021

Maria Gladkikh
Affiliation:
University of Ottawa, Faculty of Medicine, Ottawa, ON, Canada
Hugh J. McMillan
Affiliation:
University of Ottawa, Faculty of Medicine, Ottawa, ON, Canada Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON, Canada
Andrea Andrade
Affiliation:
London Children’s Hospital, University of Western Ontario, Ottawa, ON, Canada
Cyrus Boelman
Affiliation:
British Columbia Children’s Hospital, University of British Columbia, Vancouver, BC, Canada
Ishvinder Bhathal
Affiliation:
The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
Janette Mailo
Affiliation:
Stollery Children’s Hospital, University of Alberta, Edmonton, AB, Canada
Aleksandra Mineyko
Affiliation:
Alberta Children’s Hospital, University of Calgary, Calgary, AB, Canada
Mahendranath Moharir
Affiliation:
The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
Sébastien Perreault
Affiliation:
Centre Hospitalier Sainte-Justine, University of Montreal, Montreal, QC, Canada
Jonathan Smith
Affiliation:
Vancouver General Hospital, Vancouver Stroke Program, University of British Columbia, Vancouver, BC, Canada
Daniela Pohl*
Affiliation:
University of Ottawa, Faculty of Medicine, Ottawa, ON, Canada Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON, Canada
*
Correspondence to: Daniela Pohl, MD, PhD, Children’s Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, ONK1H 8L1, Canada. Email: dpohl@cheo.on.ca

Abstract:

Background:

Childhood acute arterial ischemic stroke (AIS) is diagnosed at a median of 23 hours post-symptom onset, delaying treatment. Pediatric stroke pathways can expedite diagnosis. Our goal was to understand the similarities and differences between Canadian pediatric stroke protocols with the aim of optimizing AIS management.

Methods:

We contacted neurologists at all 16 Canadian pediatric hospitals regarding AIS management. Established protocols were analyzed for similarities and differences in eight domains.

Results:

Response rate was 100%. Seven (44%) centers have an established AIS protocol and two (13%) have a protocol under development. Seven centers do not have a protocol; two redirect patients to adult neurology, five rely on a case-by-case approach for management. Analysis of the seven protocols revealed differences in: 1) IV-tPA dosage: age-dependent 0.75–0.9 mg/kg (N = 1) versus age-independent 0.9 mg/kg (N = 6), with maximum doses of 75 mg (N = 1) or 90 mg (N = 6); 2) IV-tPA lower age cut-off: 2 years (N = 5) versus 3 or 10 years (each N = 1); 3) IV-tPA exclusion criteria: PedNIHSS score <4 (N = 3), <5 (N = 1), <6 (N = 3); 4) first choice of pre-treatment neuroimaging: computed tomography (CT) (N = 3), magnetic resonance imaging (MRI) (N = 2) or either (N = 2); 5) intra-arterial tPA use (N = 3) and; 6) mechanical thrombectomy timeframe: <6 hour (N = 3), <24 hour (N = 2), unspecified (N = 2).

Conclusions:

Although 44% of Canadian pediatric hospitals have established AIS management pathways, several differences remain among centers. Some criteria (dosage, imaging) reflect adult AIS literature. Canadian expert consensus regarding IV-tPA and endovascular treatment should be established to standardize and implement AIS protocols across Canada.

Résumé :

RÉSUMÉ :

Protocoles de prise en charge d’enfants victimes d’un AVC artériel ischémique cérébral hyper aigu qui sont soignés au sein d’hôpitaux canadiens de soins tertiaires.

Contexte :

Chez les enfants, les AVC artériels ischémiques (AVCAI) aigus sont diagnostiqués 23 heures (médiane) après l’apparition de leurs premiers symptômes, ce qui entraîne des délais dans l’administration d’un traitement. Des protocoles de prise en charge qui leur spécifiquement dédiés peuvent faire en sorte d’accélérer l’établissement d’un diagnostic. Notre objectif est ici de comprendre les similitudes et les différences entre divers protocoles canadiens de prise en charge des AVCAI chez les enfants, et ce, dans le but d’améliorer justement cette prise en charge.

Méthodes :

Pour ce faire, nous avons contacté des neurologues à l’œuvre au sein des 16 hôpitaux canadiens pour enfants. Nous avons analysé les protocoles de prise en charge en vigueur et cherché à faire émerger des similitudes et des différences dans huit domaines.

Résultats :

Notre taux de réponse a été de 100 %. Au total, sept établissements, soit 44 % d’entre eux, ont adopté un protocole de prise en charge des AVCAI alors que deux, soit 13 %, en avaient un en voie d’élaboration. C’est donc dire que sept établissements n’ont aucun protocole de ce type. Dans ce cas, deux d’entre eux redirigent leurs jeunes patients vers un service de neurologie pour adultes tandis que les cinq autres s’appuient sur une approche au cas par cas. Notre analyse de ces sept protocoles a révélé des différences en ce qui concerne : 1) le dosage de l’altéplase par voie intraveineuse : 0,75-0,9 mg/kg en fonction de l’âge (n = 1) contre 0,9 mg/kg en fonction de l’âge (n = 6) avec des doses maximales de 75 mg (n = 1) ou de 90 mg (n = 6) ; 2) la limite inférieure d’âge d’administration de l’altéplase par voie intraveineuse : 2 ans (n = 5) contre 3 ou 10 ans (chacun n = 1) ; 3) les critères d’exclusion d’administration de l’altéplase par voie intraveineuse : score < 4 à la Pediatric NIH Stroke Scale (PedNIHSS) (n = 3), score < 5 (n = 1), score < 6 (n = 3); 4) les première option pré-thérapeutique en matière de neuro-imagerie : TDM (n = 3), IRM (n = 2) ou les deux (n = 2) ; 5) l’utilisation intra-artérielle de l’altéplase (n = 3) ; et 6) les délais pour procéder à une thrombectomie mécanique : < 6 h (n = 3), < 24 h (n = 2), non précisé (n = 2).

Conclusions :

Bien que 44% des hôpitaux pour enfants du Canada aient établi un protocole de prise en charge des AVCAI, plusieurs différences subsistent d’un établissement à l’autre. Un certain nombre de critères, par exemple le dosage et le recours à la neuro-imagerie, reflètent davantage les observations qu’on trouve dans la littérature portant sur des cas d’AVCAI d’adultes. Un consensus parmi les experts canadiens en ce qui regarde l’administration d’altéplase et les traitements endovasculaires devrait être établi afin qu’on puisse standardiser les protocoles de prise en charge des AVCAI partout au Canada et les mettre en pratique.

Type
Original Article
Copyright
© The Author(s), 2021. Published by Cambridge University Press on behalf of The Canadian Journal of Neurological Sciences Inc.

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Ferriero, DM, Fullerton, HJ, Bernard, TJ, et al. Management of stroke in neonates and children: a scientific statement from the American Heart Association/American stroke association. Stroke. 2019;50:e5196.10.1161/STR.0000000000000183CrossRefGoogle ScholarPubMed
deVeber, GA, Kirton, A, Booth, FA, et al. Epidemiology and outcomes of arterial ischemic stroke in children: the Canadian pediatric ischemic stroke registry. Pediatric Neurol. 2017;69:5870.10.1016/j.pediatrneurol.2017.01.016CrossRefGoogle ScholarPubMed
Beslow, LA, Dowling, MM, Hassanein, SM, et al. Mortality after pediatric arterial ischemic stroke. Pediatrics. 2018;141:e20174146.10.1542/peds.2017-4146CrossRefGoogle ScholarPubMed
DeVeber, GA, MacGregor, D, Curtis, R, Mayank, S. Neurologic outcome in survivors of childhood arterial ischemic stroke and sinovenous thrombosis. J Child Neurol. 2000;15:316–24.10.1177/088307380001500508CrossRefGoogle ScholarPubMed
Kirton, A, DeVeber, G, Pontigon, AM, et al. Presumed perinatal ischemic stroke: vascular classification predicts outcomes. Ann Neurol. 2008;63:436–43.10.1002/ana.21334CrossRefGoogle ScholarPubMed
Rafay, MF, Pontigon, AM, Chiang, J, et al. Delay to diagnosis in acute pediatric arterial ischemic stroke. Stroke. 2009;40:5864.10.1161/STROKEAHA.108.519066CrossRefGoogle ScholarPubMed
Boulanger, JM, Lindsay, MP, Gubitz, G, et al. Canadian stroke best practice recommendations for acute stroke management: prehospital, emergency department, and acute inpatient stroke care, 6th edition, update 2018. Int J Stroke. 2018;13:949–84.10.1177/1747493018786616CrossRefGoogle ScholarPubMed
Bernard, TJ, Friedman, NR, Stence, NV, et al. Preparing for a ‘pediatric Stroke Alert’. Pediatr Neurol. 2016;56:1824.10.1016/j.pediatrneurol.2015.10.012CrossRefGoogle Scholar
Roach, ES, Golomb, MR, Adams, R et al. Management of stroke in infants and children: a scientific statement from a special writing group of the American heart association stroke council and the council on cardiovascular disease in the young. Stroke. 2008;39:2644–91.10.1161/STROKEAHA.108.189696CrossRefGoogle Scholar
Amlie-Lefond, C, deVeber, G, Chan, AK, et al. Use of alteplase in childhood arterial ischaemic stroke: a multicentre, observational, cohort study. Lancet Neurol. 2009;8:530–6.10.1016/S1474-4422(09)70106-1CrossRefGoogle ScholarPubMed
DeLaroche, AM, Sivaswamy, L, Farooqi, A, Kannikeswaran, N. Pediatric stroke clinical pathway improves the time to diagnosis in an emergency department. Pediatr Neurol. 2016;65:3944.10.1016/j.pediatrneurol.2016.09.005CrossRefGoogle Scholar
Sporns, PB, Sträter, R, Minnerup, J, et al. Feasibility, safety, and outcome of endovascular recanalization in childhood stroke: the save childs study. JAMA Neurol. 2020;77:2534.10.1001/jamaneurol.2019.3403CrossRefGoogle ScholarPubMed
Rivkin, MJ, deVeber, G, Ichord, RN, et al. Thrombolysis in pediatric stroke study. Stroke. 2015;46:880–5.10.1161/STROKEAHA.114.008210CrossRefGoogle ScholarPubMed
MacKay, MT, Wiznitzer, M, Benedict, SL, et al. Arterial ischemic stroke risk factors: the International Pediatric Stroke study. Ann Neurol. 2011;69:130–40.10.1002/ana.22224CrossRefGoogle ScholarPubMed
Pexman, JW, Barber, PA, Hill, MD, et al. Use of the Alberta stroke program early CT score (ASPECTS) for assessing CT scans in patients with acute stroke. Am J Neuroradiol. 2011;22:1534–42.Google Scholar
Medley, TL, Miteff, C, Andrews, I, et al. Australian clinical consensus guideline: the diagnosis and acute management of childhood stroke. Int J Stroke. 2019;14:94106.10.1177/1747493018799958CrossRefGoogle ScholarPubMed
Benedict, SL, Ni, OK, Schloesser, P, White, KS, Bale, JF. Intra-arterial thrombolysis in a 2-year-old with cardioembolic stroke. J Child Neurol. 2007;22:225–7.10.1177/0883073807300296CrossRefGoogle Scholar
Arnold, M, Steinlin, M, Baumann, A, et al. Thrombolysis in childhood stroke report of 2 cases and review of the literature. Stroke. 2009;40:801–7.10.1161/STROKEAHA.108.529560CrossRefGoogle ScholarPubMed
Powers, WJ, Rabinstein, Alejandro A, Ackerson, Teri, et al. 2018 Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2018;49:e4699.10.1161/STR.0000000000000158CrossRefGoogle ScholarPubMed
Amlie-Lefond, C, Wainwright, MS. Organizing for acute arterial ischemic stroke in children. Stroke. 2019;50:3662–8.10.1161/STROKEAHA.119.025497CrossRefGoogle ScholarPubMed
Nogueira, RG, Jadhav, AP, Haussen, DC, et al. Thrombectomy 6 to 24 hours after stroke with a mismatch between deficit and infarct. N Engl J Med. 2017;378:1121.10.1056/NEJMoa1706442CrossRefGoogle ScholarPubMed
Bhatia, K, Kortman, H, Blair, C, et al. Mechanical thrombectomy in pediatric stroke: systematic review, individual patient data meta-analysis, and case series. J Neurosurg: Pediatr. 2019;24:558–71.Google Scholar
1
Cited by

Save article to Kindle

To save this article to your Kindle, first ensure coreplatform@cambridge.org is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about saving to your Kindle.

Note you can select to save to either the @free.kindle.com or @kindle.com variations. ‘@free.kindle.com’ emails are free but can only be saved to your device when it is connected to wi-fi. ‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

Find out more about the Kindle Personal Document Service.

Pediatric Hyperacute Arterial Ischemic Stroke Pathways at Canadian Tertiary Care Hospitals
Available formats
×

Save article to Dropbox

To save this article to your Dropbox account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you used this feature, you will be asked to authorise Cambridge Core to connect with your Dropbox account. Find out more about saving content to Dropbox.

Pediatric Hyperacute Arterial Ischemic Stroke Pathways at Canadian Tertiary Care Hospitals
Available formats
×

Save article to Google Drive

To save this article to your Google Drive account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you used this feature, you will be asked to authorise Cambridge Core to connect with your Google Drive account. Find out more about saving content to Google Drive.

Pediatric Hyperacute Arterial Ischemic Stroke Pathways at Canadian Tertiary Care Hospitals
Available formats
×
×

Reply to: Submit a response

Please enter your response.

Your details

Please enter a valid email address.

Conflicting interests

Do you have any conflicting interests? *